Provider Demographics
NPI:1740491877
Name:UDOFIA, IMABONG (RPH)
Entity type:Individual
Prefix:MISS
First Name:IMABONG
Middle Name:
Last Name:UDOFIA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19180 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3207
Mailing Address - Country:US
Mailing Address - Phone:248-569-3036
Mailing Address - Fax:
Practice Address - Street 1:15531 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2222
Practice Address - Country:US
Practice Address - Phone:313-272-0202
Practice Address - Fax:313-272-9892
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032030183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist